Life Off-Label

I’ve hesitated to post about the medication error that occurred in Nashville. I wanted to let more facts come to light and take some time to process this myself. If you’ve never worked in an IV room, “they gave potassium instead of anesthetic” sounds impossible. Unforgivable, even. I have made IVs for the better part of the last 17 years both as a technician and a pharmacist, and the uncomfortable truth is that I can totally see why it happened.

I love making IVs, and I take a lot of pride in making sure the right IV gets to the right patient every time. But I am human. We all are, and humans make mistakes. These mistakes don’t happen because we are careless. I’ve even seen accusations that this was intentional. We don’t have the details, but I think the more likely scenario is that this happened to a good pharmacist who had a brief moment on autopilot and wishes with everything they have that they could take it back.

If you’ve ever accidentally grabbed the pepper instead of the salt while making dinner, then maybe you can understand how, in a rush, a tech can accidentally grab the wrong vial (especially one that looks similar to the right one). If you’ve ever taken your eyes off your child for just a few moments while they write marker all over the walls, then maybe you can understand how a distracted pharmacist might not take those few extra moments to double check every single vial as diligently as they should. But this isn’t just messing up a dinner. Patients have suffered.

This event is weighing on a lot of us in pharmacy because we know we are all just one ordinary moment away from doing something similar. Taking a phone call while verifying an order. Leaving one hood to check the STAT in the next one. These little distractions happen to us many times throughout the day.

So how do we protect each other from those moments? Aviation figured this out decades ago: below 10,000 feet, pilots aren’t allowed to talk about anything except flying the plane. They call it the sterile cockpit. 

What if pharmacy had its own version? I get that a perfectly distraction-free pharmacy is not going to happen. Healthcare is chaotic, and some of that chaos is part of the job. But a cockpit isn’t quiet either. The rule doesn’t protect the whole flight. It protects the few minutes closest to the ground. What can we do to better protect ours?